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- Care Coordination(3)
- Communication Improvement(18)
- Culture of Safety(8)
- Education and Training(5)
- Error Reporting and Analysis(17)
- Human Factors Engineering(4)
- Legal and Policy Approaches(12)
- Logistical Approaches(31)
- Policies and Operations(14)
- Quality Improvement Strategies(12)
- Research Directions(9)
- Specialization of Care(3)
- Technologic Approaches(8)
- Transparency and Accountability(2)
- Device-Related Complications(1)
- Diagnostic Errors(19)
- Discontinuities, Gaps, and Hand-Off Problems(94)
- Interruptions and distractions(3)
- Medical Complications(17)
- Medication Safety(6)
- Nonsurgical Procedural Complications(2)
- Psychological and Social Complications(9)
- Second victims(1)
- Surgical Complications(2)
- Transitions of Care(1)
A 72-year-old man was diagnosed with COVID-19 pneumonia and ileus, and admitted to a specialized COVID care unit. A nasogastric tube (NGT) was placed, supplemental oxygen was provided, and oral feedings were withheld. Early in his hospital stay, the patient developed hyperactive delirium and pulled out his NGT. Haloperidol was ordered for use as needed (“prn”) and the nurse was asked to replace the NGT and confirm placement by X-ray. The bedside and charge nurses had difficulty placing the NGT and the X-ray confirmation was not done.
A 71-year-old man presented to his physician with rectal bleeding and pain, which was attributed to radiation proctitis following therapy for adenocarcinoma of the prostate. He subsequently developed a potentially life-threatening complication of sepsis while awaiting follow up care for a spontaneous rectal perforation. The commentary addresses the importance of early identification and timely intervention in the event of treatment failure and the post-discharge follow-up programs to improve care coordination and communication during transitions of care.
Appropriate follow-up of incidental abnormal radiological findings is an ongoing patient safety challenge. Inadequate follow-up can contribute to missed or delayed diagnosis, potentially resulting in poorer patient outcomes. This study describes implementation of an electronic health record-based referral system for patients with incidental radiologic finding in the emergency room.
A 61-year-old women with a mechanical aortic valve on chronic warfarin therapy was referred to the emergency department (ED) for urgent computed tomography (CT) imaging of the right leg to rule out an arterial clot. CT imaging revealed two arterial thromboses the right lower extremity and an echocardiogram revealed a thrombus near the prosthetic heart valve. The attending physician ordered discontinuation of warfarin and initiation of a heparin drip.
Zimolzak AJ, Singh H, Murphy DR, et al. BMJ Health Care Inform. 2022;29(1):e100565.
This Spotlight Case describes an older man incidentally diagnosed with prostate cancer, with metastases to the bone. He was seen in clinic one month after that discharge, without family present, and scheduled for outpatient biopsy. He showed up to the biopsy without adequate preparation and so it was rescheduled. He did not show up to the following four oncology appointments.